PHSA Mobile MRI Trailer Request Form
Please select your Health Authority
Fraser Health
Interior Health
Island Health
Northern Health
Providence Health Care
Provincial Health Services Authority
Vancouver Coastal Health
*
Please provide your site and contact information
Name
Title
*
Site
*
Site Address
*
Phone number
*
Email
*
Please select your reason for request
Select:
MRI Replacement
MRI Refurbishment
MRI Unexpected Downtime
Other
*
Requested date for trailer arrival
*
Expected date for trailer departure
Additional comments: